El Internado de Pregrado

Desde un punto de vista general, podemos definir “el internado” como el lapso correspondiente al último año de formación en nuestra carrera de medicina, en el cual el estudiante tendrá la tarea de aplicar todos los conocimientos adquiridos en los años previos, en el diagnóstico y tratamiento de los pacientes, bajo la supervisión de médicos residentes y especialistas. Sin embargo, “el internado” es mucho más que una pasantía de un año, rotando por varios servicios de un hospital. Por primera vez el estudiante de medicina se siente verdaderamente médico, siendo finalmente capaz de materializar con sus actos la curación del enfermo

Ultrasonido endoscópico en el diagnóstico de síndrome de Mirizzi

Mirizzi’s syndrome is a rare and difficult to manage clinical entity. However, recent technological advances provide new options for a more effective diagnosis and treatment of it. In this case report, the most used diagnostic modalities are described, such as ultrasound, Computed Tomography, Magnetic Resonance Cholangiopancreatography, Endoscopic Retrograde Cholangiopancreatography. We want to highlight the use of ENDOSCOPIC ULTRASOUND (EUS), as a diagnostic tool, very little described in this pathology (according to the revised bibliography) and, in this case, specifically determine the surgical conduct to follow, knowing that statistically this preoperative diagnosis is very low (0.06 to 5.7%) and 1.07% in the CPRE carried out. Therefore, there are great difficulties in making a pre-surgical diagnosis, and in addition to knowing that this pathology is associated with an increase in surgical iatrogenesis of the bile ducts, related to technical difficulties that increase the risk of complications such as fistulae and injury to the bile ducts. Therefore, we consider EUS a first-line diagnostic method to be used since it allows the complete evaluation of the bile duct, the gallbladder and the cystic duct, which are the places where the Mirizzi’s occurs. It should be noted that it is the first article published in Venezuela with a literature review.El síndrome de Mirizzi es una entidad clínica rara y difícil de manejar. Sin embargo, los avances tecnológicos recientes proporcionan nuevas opciones para un diagnóstico y tratamiento más efectivos de esta condición. En este reporte de caso, se describen las modalidades diagnósticas más utilizadas como son ecografía, TAC, CPRM, CPRE. Queremos resaltar el uso del ultrasonido endoscópico (USE), como herramienta diagnóstica, muy poco descrita en esta patología (según bibliografía revisada) y en este caso particular determinó la conducta quirúrgica a seguir, conociéndose que estadísticamente este diagnóstico preoperatorio es muy bajo (0,06 a 5.7%) y en 1.07% en las PCRE realizadas. Por lo tanto, las grandes dificultades que se tiene para realizar un diagnóstico pre quirúrgico, y además de conocer que esta patología está asociada con incremento en la iatrogenia quirúrgica de los conductos biliares, relacionadas a las dificultades técnicas que aumenta el riesgo de complicaciones como fístulas e injuria a los ductos biliares. Por lo tanto, consideramos el USE un método diagnóstico a utilizar de primera línea ya que permite la evaluación completa del ducto biliar, la vesícula y cístico, que son los lugares en donde el Mirizzi se localiza. Es de hacer notar que es el primer trabajo que se publica en Venezuela con revisión de la literatura

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries.

BACKGROUND There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates. METHODS We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020. RESULTS Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country. CONCLUSIONS BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak

Effect of BMI on safety of bariatric surgery during the COVID-19 pandemic, procedure choice, and safety protocols - An analysis from the GENEVA Study

Background: It has been suggested that patients with a Body Mass Index (BMI) of > 60 kg/m2 should be offered expedited Bariatric Surgery (BS) during the Coronavirus Disease-2019 (COVID-19) pandemic. The main objective of this study was to assess the safety of this approach. Methods: We conducted a global study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into three groups according to their preoperative BMI -Group I (BMI < 50 kg/m2), Group II (BMI 50-60 kg/m2), and Group III (BMI > 60 kg/m2). The effect of preoperative BMI on 30-day morbidity and mortality, procedure choice, COVID-19 specific safety protocols, and comorbidities was assessed. Results: This study included 7084 patients (5197;73.4 % females). The mean preoperative weight and BMI were 119.49 & PLUSMN; 24.4 Kgs and 43.03 & PLUSMN; 6.9 Kg/m2, respectively. Group I included 6024 (85 %) patients, whereas Groups II and III included 905 (13 %) and 155 (2 %) patients, respectively.The 30-day mortality rate was higher in Group III (p = 0.001). The complication rate and COVID-19 infection were not different. Comorbidities were significantly more likely in Group III (p = < 0.001). A significantly higher proportion of patients in group III received Sleeve Gastrectomy or One Anastomosis Gastric Bypass compared to other groups. Patients with a BMI of > 70 kg/m2 had a 30-day mortality of 7.7 % (2/26). None of these patients underwent a Roux-en-Y Gastric Bypass. Conclusion: The 30-day mortality rate was significantly higher in patients with BMI > 60 kg/m2. There was, however, no significant difference in complications rates in different BMI groups, probably due to differences in procedure selection

Safety of Bariatric Surgery in ≥ 65-Year-Old Patients During the COVID-19 Pandemic

Background Age >= 65 years is regarded as a relative contraindication for bariatric surgery. Advanced age is also a recognised risk factor for adverse outcomes with Coronavirus Disease-2019 (COVID-19) which continues to wreak havoc on global populations. This study aimed to assess the safety of bariatric surgery (BS) in this particular age group during the COVID-19 pandemic in comparison with the younger cohort.Methods We conducted a prospective international study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into two groups - patients >= 65-years-old (Group I) and patients < 65-years-old (Group II). The two groups were compared for 30-day morbidity and mortality.Results There were 149 patients in Group 1 and 6923 patients in Group II. The mean age, preoperative weight, and BMI were 67.6 +/- 2.5 years, 119.5 +/- 24.5 kg, and 43 +/- 7 in Group I and 39.8 +/- 11.3 years, 117.7 +/- 20.4 kg, and 43.7 +/- 7 in Group II, respectively. Approximately, 95% of patients in Group 1 had at least one co-morbidity compared to 68% of patients in Group 2 (p = < 0.001). The 30-day morbidity was significantly higher in Group I ( 11.4%) compared to Group II (6.6%) (p = 0.022). However, the 30-day mortality and COVID-19 infection rates were not significantly different between the two groups.Conclusions Bariatric surgery during the COVID-19 pandemic is associated with a higher complication rate in those >= 65 years of age compared to those < 65 years old. However, the mortality and postoperative COVID-19 infection rates are not significantly different between the two groups

30-Day morbidity and mortality of bariatric metabolic surgery in adolescence during the COVID-19 pandemic – The GENEVA study

Background: Metabolic and bariatric surgery (MBS) is an effective treatment for adolescents with severe obesity. Objectives: This study examined the safety of MBS in adolescents during the coronavirus disease 2019 (COVID-19) pandemic. Methods: This was a global, multicentre and observational cohort study of MBS performed between May 01, 2020, and October 10,2020, in 68 centres from 24 countries. Data collection included in-hospital and 30-day COVID-19 and surgery-specific morbidity/mortality. Results: One hundred and seventy adolescent patients (mean age: 17.75 ± 1.30 years), mostly females (n = 122, 71.8%), underwent MBS during the study period. The mean pre-operative weight and body mass index were 122.16 ± 15.92 kg and 43.7 ± 7.11 kg/m2, respectively. Although majority of patients had pre-operative testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (n = 146; 85.9%), only 42.4% (n = 72) of the patients were asked to self-isolate pre-operatively. Two patients developed symptomatic SARS-CoV-2 infection post-operatively (1.2%). The overall complication rate was 5.3% (n = 9). There was no mortality in this cohort. Conclusions: MBS in adolescents with obesity is safe during the COVID-19 pandemic when performed within the context of local precautionary procedures (such as pre-operative testing). The 30-day morbidity rates were similar to those reported pre-pandemic. These data will help facilitate the safe re-introduction of MBS services for this group of patients